[Prolonged weaning during early neurological and neurosurgical rehabilitation : S2k guideline published by the Weaning Committee of the German Neurorehabilitation Society (DGNR)]. / Prolongiertes Weaning in der neurologisch-neurochirurgischen Frührehabilitation : S2k-Leitlinie herausgegeben von der Weaning-Kommission der Deutschen Gesellschaft für Neurorehabilitation e. V. (DGNR).

Prolonged weaning of patients with neurological or neurosurgery disorders is associated with specific characteristics, which are taken into account by the German Society for Neurorehabilitation (DGNR) in its own guideline. The current S2k guideline of the German Society for Pneumology and Respiratory Medicine is referred to explicitly with regard to definitions (e.g., weaning and weaning failure), weaning categories, pathophysiology of weaning failure, and general weaning strategies. In early neurological and neurosurgery rehabilitation, patients with central of respiratory regulation disturbances (e.g., cerebral stem lesions), swallowing disturbances (neurogenic dysphagia), neuromuscular problems (e.g., critical illness polyneuropathy, Guillain-Barre syndrome, paraplegia, Myasthenia gravis) and/or cognitive disturbances (e.g., disturbed consciousness and vigilance disorders, severe communication disorders), whose care during the weaning of ventilation requires, in addition to intensive medical competence, neurological or neurosurgical and neurorehabilitation expertise. In Germany, this competence is present in centers of early neurological and neurosurgery rehabilitation, as a hospital treatment. The guideline is based on a systematic search of guideline databases and MEDLINE. Consensus was established by means of a nominal group process and Delphi procedure moderated by the Association of the Scientific Medical Societies in Germany (AWMF). In the present guideline of the DGNR, the special structural and substantive characteristics of early neurological and neurosurgery rehabilitation and existing studies on weaning in early rehabilitation facilities are examined.Addressees of the guideline are neurologists, neurosurgeons, anesthesiologists, palliative physicians, speech therapists, intensive care staff, ergotherapists, physiotherapists, and neuropsychologists. In addition, this guideline is intended to provide information to specialists for physical medicine and rehabilitation (PMR), pneumologists, internists, respiratory therapists, the German Medical Service of Health Insurance Funds (MDK) and the German Association of Health Insurance Funds (MDS). The main goal of this guideline is to convey the current knowledge on the subject of "Prolonged weaning in early neurological and neurosurgery rehabilitation".

Continuous monitoring of jugular bulb oxygen saturation in comatose patients--therapeutic implications.

Comatose patients run a high risk of developing cerebral ischaemia which may considerably influence final outcome. It would therefore be extremely useful if one could monitor cerebral blood flow in these patients. Since there is a close correlation between the arteriovenous difference of oxygen and cerebral blood flow, it was a logical step to place a fiberoptic catheter in the jugular bulb for continuous measurement of cerebrovenous oxygen saturation. We have monitored cerebral oxygenation in 54 patients, comatose because of severe head injury, intracerebral haemorrhage or subarachnoid haemorrhage. Normal jugular venous oxygen saturation (SJVO2) ranges between 60 and 90%. A decline to below 50% is considered indicative of cerebral ischaemia. Spontaneous episodes of desaturation (SJVO2 < 50% for at least 15 min) were frequent during the acute phase of these insults. Many of these desaturation episodes could be attributed to hyperventilation, even though considered moderate. Likewise, insufficient cerebral perfusion pressure and severe vasospasm were found to be important causes of desaturation episodes. In many instances, tailoring of ventilation or induced hypervolaemia and hypertension were capable of reversing these low flow states. The new method of continuous cerebrovenous oximetry is expected to contribute to a better outcome by enabling timely detection and treatment of insufficient cerebral perfusion.

Monitoring of jugular venous oxygen saturation in comatose patients with subarachnoid haemorrhage and intracerebral haematomas.

To prevent secondary cerebral ischemia in comatose patients it would be of great importance to assess cerebral blood flow. Recently monitoring of the jugular venous oxygen saturation (SJVO2) has been shown to continuously evaluate cerebral oxygenation and to estimate cerebral blood flow. While most of these studies have dealt with severely head injured patients, we investigated cerebral oxygenation in 50 comatose patients due to an intracerebral haematoma (n = 14), subarachnoid haemorrhage (n = 12) and severe head injury (n = 24). In these groups of patients, the reaction of SJVO2 to hyperventilation and to lowering of blood pressure was studied. Moderate hyperventilation from 35 to 28 mmHg resulted in a significant decrease of SJVO2 in all groups. A critical SJVO2 between 50 and 55% was found in one half of the patients studied, a pathological SJVO2 below 50% was seen in 23% of the cases. Lowering of arterial blood pressure within the limits of autoregulation resulted in decreases of SJVO2 in patients with intracerebral haematomas only. 55% of these patients showed signs of insufficient cerebral oxygenation. Furthermore the frequency of spontaneous desaturation episodes was studied retrospectively and comparison made between the different groups. These episodes were found more frequently in patients with intracerebral haematomas compared to patients with severe head injury. In conclusion, monitoring of jugular venous oxygen saturation is a valuable tool for detecting and treating insufficient cerebral oxygenation in comatose patients following intracerebral haemorrhage, subarachnoid haemorrhage and severe head injury.